HomeMy WebLinkAboutWEC2004-00261 - WEC Application - 12/30/2004 ,. cSc.
MASON COUNTY
' DEPARTMENT OF HEALTH SERVICES
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360)275-4467
WEB http://www.co.mason.wa.us FAX (360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
RECEIVED ReceiptNumber:.,,V WEC:
DEC 3 0 2004 1. Complete Part 1, incomplete applications will not be accepted
2. Attach a plot plan and vicinity map
426 W. CEDAR STi 3. Submit this completed application with appropriate fee(s)a minimum of 24 hours
in advance of initiating well construction.
Date Received 4. The Mason County Health Dept. must receive notification at least 24 hours prior to
the drilling of the well
PART 1:Applicant/Parcel Identification
Site Address XX X A'l.-kkels.�, R.✓ Start Card#
Drilling Firm /f ��K/seY Iue.1/ Phone 253`537-7332
Applicant <y)�p4g,,,,c � ae,,elg�omc.,7- (0/(js Tnc Phone 9e2es-b/�/
Mailing Address /o Qc�aw�sa,, Gla// ��.1/.N� R. o . Q yv y2 >
City / tomes ( State ZLIA _ ZIP 9,? 1/
Parcel Number 9O0 ,?
Directions to Site Jake lFw 3 -o r!'1as. I.,k, Qn le,F7 4 n/.,khIs,
4zr✓ tf 77— L,.' . dcW[/ Si d s0 /, 7'r
caw
Is the well site within 100 feet of salt/seawater? ❑Yes �No Ila 7— h./- ..1�efT
If yes, a variance from DOE is required. Have you applied jj received (circle one)a variance? ❑Yes ❑No
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO/ TAG# ►f I Called In 1 - 7
❑ [jY Driller on Site?
( ❑ Is the well capped and Vented?
❑ Is there evidence of a surface seal?
Ld` ❑—/ Is there a 2"annular space on all sides of the casing?
❑ L� Has the seal Slumped?
❑ &� Is the;well flowing or is there evidence of other leakage?
❑ Lys Is there evidence of cascading water?
❑ Is there evidence that the seal is at least 18 feet long?
LN' ❑ Do the well site set-backs appear to be appropriate?
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